Provider Demographics
NPI:1275574824
Name:DURELL, KEVIN (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:DURELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48068-0100
Mailing Address - Country:US
Mailing Address - Phone:248-849-3015
Mailing Address - Fax:
Practice Address - Street 1:6245 INKSTER RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-4001
Practice Address - Country:US
Practice Address - Phone:734-458-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013226207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114454656Medicaid
MI114703386Medicaid
MIKD013226OtherBC/BS OF MICHIGAN
MI114308362Medicaid
MI114454665Medicaid
MIM48310037Medicare ID - Type Unspecified
MI114308362Medicaid